Patient on nightly trazodone 50–150 mg and prazosin 1–5 mg presents with epistaxis and xerostomia; are these adverse effects of the medications and what is the recommended management?

Management of Epistaxis and Xerostomia in Patients on Trazodone and Prazosin

Both nosebleeds and dry mouth are well-documented adverse effects of trazodone, and you should address these symptoms with local measures while continuing the medications unless bleeding becomes severe.

Attribution of Adverse Effects

Trazodone-Related Side Effects

• Dry mouth (xerostomia) is a common adverse effect of trazodone, occurring frequently enough to cause 19% of patients in one study to discontinue the medication specifically due to "severe dry mouth and sinuses." 1
• Trazodone commonly causes drowsiness, dizziness, headache, and dry mouth as its most frequent adverse effects. 2
• The anticholinergic activity of trazodone, though minimal compared to tricyclic antidepressants, still produces dry mouth in a significant proportion of patients. 3

Prazosin-Related Side Effects

• Prazosin shares the potential for orthostatic hypotension with other alpha-adrenergic antagonists, which can contribute to dizziness and falls. 1
• While prazosin itself is not directly cited as causing epistaxis in the provided guidelines, alpha-blockers can theoretically contribute to nasal mucosal changes.

Epistaxis Attribution

• Neither trazodone nor prazosin is listed among the primary drug classes associated with epistaxis (anticoagulants, antiplatelets, SSRIs, intranasal corticosteroids are the main culprits). 4
• However, trazodone was associated with "severe dry mouth and sinuses" in 19% of discontinuations, suggesting significant mucosal drying that could predispose to nosebleeds. 1
• The combination of mucosal drying from trazodone and potential vascular effects may create conditions favorable for epistaxis.

Management Strategy

For Epistaxis (Nosebleeds)

Immediate Control

• Apply firm, continuous pressure to the soft lower third of the nose for 10–15 minutes without checking for cessation of bleeding; premature release is the most common cause of treatment failure. 5, 6
• After initial compression, apply a topical vasoconstrictor (oxymetazoline or phenylephrine, 2 sprays into the bleeding nostril) and resume firm compression for an additional 5–10 minutes. 6

Prevention of Recurrence

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence. 5, 6
• Use saline nasal sprays frequently throughout the day to keep the nasal mucosa moist. 5, 6
• Recommend a humidifier in dry environments, since dry heat creates fragile, hyperemic nasal mucosa that bleeds easily. 6

When to Escalate

• Perform anterior rhinoscopy to identify the bleeding source after clot removal if bleeding recurs. 1, 5
• Refer to ENT if bleeding persists despite appropriate local measures, recurs more than 3 times, or continues for more than 30 minutes in a 24-hour period. 5, 6

For Xerostomia (Dry Mouth)

Symptomatic Management

• Encourage frequent sips of water throughout the day.
• Recommend sugar-free gum or lozenges to stimulate saliva production.
• Consider artificial saliva products for severe cases.
• Advise meticulous oral hygiene to prevent dental complications from chronic dry mouth.

Medication Adjustment Considerations

• Trazodone can be given as a single night-time dose rather than divided doses, which reduces daytime side effects including dry mouth while maintaining therapeutic efficacy. 7
• The dose range of trazodone (50-150 mg in this patient) is within the therapeutic range, but administering the full dose at bedtime may reduce daytime xerostomia complaints. 7
• Do not discontinue trazodone or prazosin solely for these side effects unless they become intolerable or bleeding becomes life-threatening. 1, 6

Medication Continuation vs. Discontinuation

Continue Both Medications If:

• Epistaxis is controlled with local measures (compression, moisturization, vasoconstrictors). 6
• Dry mouth is manageable with symptomatic treatment.
• The patient is deriving therapeutic benefit from these medications for their primary indications (likely PTSD-related nightmares or insomnia).

Consider Medication Adjustment If:

• Epistaxis becomes recurrent (>3 episodes) despite proper preventive measures. 5
• Bleeding persists for more than 30 minutes in a 24-hour period. 6
• Xerostomia is severe enough to cause dental complications or significantly impair quality of life.
• The patient develops other intolerable side effects (orthostatic hypotension, excessive sedation).

Common Pitfalls to Avoid

• Do not tilt the head backward during nosebleeds; this directs blood into the throat and does not aid hemostasis. 8
• Do not check if bleeding has stopped before the full 10-15 minutes of compression—insufficient compression time is the single most common error. 5, 6
• Do not immediately discontinue medications that are providing therapeutic benefit for the primary psychiatric indication without attempting local management first. 1, 6
• Do not overlook the need for nasal moisturization, which is the key preventive measure for medication-related mucosal drying. 5, 6

Documentation and Follow-Up

• Document the frequency and severity of epistaxis episodes. 1, 5
• Record response to local measures and preventive strategies. 5
• Reassess within 30 days if bleeding recurs despite preventive measures. 5
• Monitor for signs requiring urgent evaluation: hemodynamic instability, bleeding lasting >30 minutes, or fever >101°F. 8, 6